What's the scoop on bruising

[Aggie85]

Tried to do a search on the issue of bruising, but didn't find anything that really answered my questions, so here goes. Please feel free to let me know if there is something from here that I just didn't dig deep enough for.

I know bruising is common and more likely when on warfarin. That the bruising isn't necessarily dangerous on its own and probably won't cause clots. BUT, I keep having mystery bruises showing up on the tops of my feet and lower legs. These bruises are NOT being caused by anything hitting my feet or legs or any other thing that I can think of. In the last 2 days I've noticed 8 bruises show up just on my feet and one leg, that are not accounted for by any physical trauma. The bruises are fairly large (good 1.5-3" each) but superficial and not tender. Other than bruises from lab blood draws, I'm not bruising significantly anywhere else.

My INR on Last Friday was a vein draw level of 3.5. My range is 2.5-3.5. So yes, on high end but not out of range. They kept me on my regular dose of 7mg/day (49/week) and told me to come back in 10 days for next test. I've been fairly stable but in the 3s for the last 4 INR tests.

QUESTIONS:
...so at what point should folks on Coumadin get concerned with bruises
...since I was on upper edge Friday and suddenly noticing LOTS of unaccounted for bruises, should I call my AC clinic and arrange to get re-tested to see if INR is higher.
...is there any significance or reason that the bruising is all on feet and lower legs
...when nothing external is causing the bruises, what's going on internally to be causing them (no petichea or broken blood vessels showing up)
...anything else we/I should know about bruising but don't know to ask
???????

Thanks,
Cruis'n for bruis'n,
Linda

 

[epstns]

The others with warfarin-specific experience will be here soon, but I can tell you that my wife, who takes Lipitor, has "random" bruising that occurs mainly on her arms and legs, but sometimes on her torso, too. I have to caution her not to let people think that I am responsible for all this. I tell her that if she tells anyone that I'm responsible, I'll question her "recreational medication" habits, too.

 

[Freddie]

I've had may fair share with bruising, in fact I have one on my thigh right now that's a size and shape of an egg if not bigger - INR 3.3 and I've had a black eye and I know how it happened in both occasions. ICE is the answer, 20 minutes on, 20 minutes off. I saw the doctor when I had the black eye, didn't seem too concern, but was told did get my INR tested and they put a rush on the sample; I was within my range of 2.5 - 3.5.

I feel that if you even touch me I'll bruise.

Yesterday I noticed two bruises on the lower part of my thumb, no idea how they got there, but this morning they are almost gone...go figure.

Check with your doctor and see what they say. This is just my experience, yours might be different.

 

[sunshine2cats]

that bottom liner could apply to me ...am scheduled for surgery in two weeks and i am a complete mess...it is now critical.
Ruth

 

[pellicle]

Tried to do a search on the issue of bruising, but didn't find anything that really answered my questions, so here goes.

one thing I've noticed about brusing is that you get more of it with age. Mum (never on warfarin or any AC therapy for that matter) used to gripe that as she got older she bruised easily. I notice that between 20 and 50 that I bruise more easily, warfarin seems to make those a little bigger.

My wife used to get spontaneous small bruises (about the size of our 2 cent coin) appear on her outter thighs (her Quadracepts). She lamented that she had fair skin and a small roadmap of capillaries slightly visible below the surface which were tending to get more obvious as she aged too.

My view is that warfarin does not cause anything, but makes what may have been happening more clear as a minor amount more of blood will leak out of the capillary break and cause the bruise to be more visible.

QUESTIONS:
...so at what point should folks on Coumadin get concerned with bruises

I think this question is best directed to a specialist of circulatory system *not* a regular doctor and certainly not any of the well meaning (but largely ignorant) technicians at the AC Clinic. From the small amount of knowledge I have in this area I'd say you'll need to concerned if you see what appears like a blood blister and a discolouration of the skin.

how long have you been on warfarin therapy now?

did you not have some recent see-sawing of your INR (caused by the drongos at your clinic)?

...since I was on upper edge Friday and suddenly noticing LOTS of unaccounted for bruises,

how many is lots? Can you photograph and post one?

should I call my AC clinic and arrange to get re-tested to see if INR is higher.

its possible that it can go up and come back in days ... its what I have seen in my INR and what Ola documented in his trial. The rubbish that its just a steady state with no fluctuation is flawed and essentially a fairy tale that is told to stop people freaking out and trying to micro manage their INR. I'd like to stress again, do not attempt to micro-manage your INR, it will only be worse.

...is there any significance or reason that the bruising is all on feet and lower legs

not that I know of...

...when nothing external is causing the bruises, what's going on internally to be causing them (no petichea or broken blood vessels showing up)

well nothing broken on the surface, but if its just below the surface you will see exactly what you seem to be reporting you are seeing.

Post a pic if you want (help to actually see what people are saying) and ask your Dr (not your AC clinic) if he/she thinks it warrants further investigation.

PS: I think an important question is "is there any pain associated with the sites of the bruises?"

You mentioned that you had said there were no paresthesias ...that's a good thing
Best Wishes

 

[Aggie85]

Pellicle,
1) I doubt this is an aging issue since it's a new occurrence (8 new bruises in 2 days), again with NO incidents of trauma. Just bruises showing up out of no where. I too noticed an increase in bruising as I get older and especially during craft show season, and even before starting Warfarin. But the point of this thread is; this is a sudden high number of bruises with no reason to explain them. I first said they weren't tender, but I noticed yesterday that actually they are tender to touch. They're not like your bruise you posted after the blood draw. These are more standard greenish tinged black and blue bruising. I'll try to get a picture today.

2) I've been on warfarin about 6 weeks now. As I mentioned in starting post, for the most part, pretty steady on 7mg daily. I'm not the one who's been bouncing up and down, I've been pretty steady actually. But I am the one who the POCs aren't working with. POC number is WAY higher than vein blood INR results. But the vein INRs have been pretty steady for the last 4 weeks in the 3.s (3.7, 3.3, 3.0, 3.5). For now AC clinic and I are ignoring the POCs since it doesn't seem to be working. BTW clinic is now consulting with Roche as to what might be going on with that (but that discussion if for the other post).

3. I agree that INRs won't be steady states. Fluctuation makes total sense to me. Totally dependent on input (diet, other factors) and daily normal fluctuations in metabolism. Beside the fact that I'm still in a healing state and that affects how my body processes things too. I'm not expecting steady state. In fact, have been surprised at how steady I've been for this early in the game.

4. I ran my knee into A car door today, I fully expect a bruise to show up tomorrow and won't be surprised. That is different than what I'm asking about. Bruising after getting hit or dropping something on me, I expect. Bruises showing up with NO explanation I don't expect.

5. What I'm trying to find out is if a sudden significant increase in unexplained bruising indicates anything going on with Coumadin levels? I was at 3.5 on Friday then over the two days of the weekend, I suddenly get 8 unexplained bruises on my feet and legs. Could it be from INR continuing to rise and getting into worrisome ranges?

Thanks,
Linda

 

[scott.eitman]

Since you are have an On-x valve, I expect your range to be lowered soon. i believe the recommended range, long-term, for On-x valves is 2-3, but it is typically higher right after surgery.

I typically do not have bruising and keep my NR pretty close to 2.5ish.

With no data to back me up, I believe the coumadin plays a role in your bruising and also expect there may be other factors in play as well. I visit many patients with bruising after surgery and am always surprised when I learn they are not on an anticoagulant.

 

[mcsf]

@aggie85 I am new to warfarin. I started taking it in February. Like you I bruise all the time now. I have small bruises on my left shin, ankle all the time. I concluded the bruising is from how I sleep. I tend to sleep on my side and noticed that one leg will rest on the other. Also at my desk at work I'll stretch out my legs and rest one foot on top of the other, hitting my shin. It's the only thing I can think of.

 

[dick0236]

5. What I'm trying to find out is if a sudden significant increase in unexplained bruising indicates anything going on with Coumadin levels? I was at 3.5 on Friday then over the two days of the weekend, I suddenly get 8 unexplained bruises on my feet and legs. Could it be from INR continuing to rise and getting into worrisome ranges?

While I have had seemingly spontaneous bruising, it happens very, very seldom and never in bunches. An INR of 3.5 normally does not cause a bruising problem for me....and I try to keep my INR above 3.0(range 2.5-3.5)......but we are all different. Since you are very new to warfarin and now having a number of unexplained bruises I'd ask my doctors about it.

 

[Agian]

FWIW I bleed like a stuck pig, on the combination of Aspirin 100mg and Plavix 75mg. I have been taking this because I had an occlusive device put in for my pfo 7 months ago. I've been given permission to stop one or the other.

The on-x trial for low risk patients is to evaluate a combination of Plavix and a higher dose of Aspirin than what I've been on (300mg, I think). I'm starting to think there's no real point, because I suspect that Warfarin is probably safer.

The on-x valve has been approved for a lower INR in Europe of 1.5. This kind of implies that it is less prone to clots, which is great news. But the advantage of an INR of 1.5 compared to 2 is probably minimal.

 

[gerrychuck]

I have a target INR of 2.5-3.5, and was on low dose aspirin for the first year and a half after surgery as well as warfarin. While I was taking both Warfarin and aspirin, I was a pretty impressive bruise factory. Since going off the aspirin, I have had minimal unexplained bruising; big improvement. I changed the steering cable on my boat a couple of weeks ago; lots of working in very confined spaces, turning wrenches, leaning on things, etc. Ended up with a few dayglo bruises on my forearms after that, but that was the only time in the past few months, and although there was no specific trauma, I know what caused it and was not surprised. Testing a few days later showed I was right at the top of my INR range, so again, no huge surprise that I might get a few "conversation pieces"

 

[Aggie85]

Hi All,
Sorry I've been off here for a while. Got HOOKED on Grey's Anatomy (had never seen it) and have done little else but watching it since. LOL. Anyway, HAD to come on today after this latest INR test (see new thread). My INR came back at 6.0!!!! With veinous draw.

Ironically NO extra bruising noted this week. What I did notice and had suspicions today's draw would be high, But NOT THAT HIGH, was that scratches from my cat on Friday (more like puncture wounds) started spontaneously bleeding this morning when they had been scabbed over all weekend and had hardly bled at all when I got them.

I can't remember who wrote what, but I'll address some of your replies. Thanks for the insights!
...not on aspirin or other thinner type drugs.
...I was thinking same thing about bruises coming from how I rest my legs when in bed possibly causing the bruises. Again, ironically with insanely high INR no extra bruising this week.
...mine is a PULMONARY valve. My INR range, even with OnX will stay at 2.5-3.5 . It is very rare to replace PVs, pretty much only us Tetrology of Fallot survivors, who need them replaced. Because the valve has not been formally tested there and because of the low pressure system (so blood more likely to pool and therefore clot) of the right side of the heart, my INR range will stay higher.

Funny note about how rare PV replacement is; I have a pharmacist friend who used to run a Coumadin clinic. When I told him about needing my PV replaced, his first comment was there isn't a PV. At first, I interpreted this as no PV in the heart and gave him guff about not knowing his anatomy better, (he never changed assertion, even when jibed) but I then realized he meant no replacement pulmonary valve on the market. There isn't, they get special permission from FDA to use Aortic valves and then adapt the valve for Pulmonary insertion. This was one reason why I had to go to Cleveland Clinic for my repair.

Anyway, resting in bed today, watching for any internal bleeding signs and making SURE I don't get any cuts!!!!

Linda

 

[Protimenow]

I don't think 3.5 would cause new bruising. High doses of aspirin MIGHT contribute, with a different mode of action on the coagulation mechanism (aspirin makes the platelets 'slippery'). If there's excessive bruising, it may not hurt to get a CBC -- in case there's a remote possibility of liver issues. A spike from 3.5 to 6.0 to me suggests that there is probably even more justification for a blood test, just to make sure that your hepatic functioning is okay and that you aren't adversely reacting to a new medication or OTC pill.

I've had INR up to 7.0 (once) and not had a major issue with bruising -- except, of course, when I did some real damage to myself (like the time I dropped a 50 pound slab or marble on my foot). I fell and broke my wrist last December, and didn't even have much bruising.

I don't think Warfarin is a likely cause of the minor bruises you mention, but am certainly interested in learning with the doctors say.

 

[Aggie85]

Not on aspirin at all. No changes in meds except Im trying to wean off Tramadol pain med. Not much luck on that except I've got it down to just taking sometime during the night if I wake up in high pain levels. Got a liver enzyme test with INR on Wed. Values were within normal limits along with INR dropping back down to 2.9 from that 6.0 on Monday.

There was no excessive bruising noted when my level spiked up to the 6.0 and the bruises I mentioned in this thread have faded and not reoccurred. So no idea what caused them. When my INR was at 6; what I did notice was I had speech problems and some scabbed cat scratch punctures from a couple days prior, started spontaneously bleeding. I discussed the speech problems at length with AC Clinician and we kept an eye on my mental status. I didn't notice any other changes and we both noticed that by Wed. my speech issues had resolved.
((I had taken Tramadol during the night before each of the blood tests. But since the speech problem disappeared as INR went down, I suspect it was the INR level and not Tramadol that caused the speech issues. Monday: Tramadol, INR of 6 and Speech issues... Wed: Tramadol, INR of 2.9 and NO speech issues.))

Linda

 

[Protimenow]

Linda -- you mentioned 'speech issues.' I sometimes get a very transient issue with the inability to form words or to speak coherently, and it usually clears up in a few minutes. I relate it to something similar to a migraine -- blood pressure, too much (or too little) caffeine, who know what? Perhaps it's something vasovagal. I often get it at about the same time as an ocular migraine. I sometimes have numbness in an extremity or the side or the tongue.

I am not sure if I first experienced it before my OHS or not.

It's somewhat worrisome no matter how often you get it, but in my case at least (thank god), it was temporary and cleared up without any residual issues. I don't think INR has much to do with it. For all I know, it may even have a dietary trigger.

I don't know if this is the same thing that you experienced, or if others get similar things, but it may be unassociated with either Tramadol or iNR.

 

[chaconne]

Aggie,

Bruising certainly happens more often for me than before Warfarin, but it usually occurs in an area that I know I hit hard. Many times I don't bruise even though I got scraped or hit an area. Are your bruises mild and hard to see, or are they dark purple?

 

[Aggie85]

Protimenow,
Mine lasted several hours, was not associated with any other head issues (no migraines or even headaches.) Nothing different in diet that I can pinpoint. I drink very little to no caffeine (mostly just water with maybe a lime or couple mint leaves in it). The only two factors was having taken the Tramadol 12 hours before the previous night and the high INR. I took Tramadol the on Tuesday night as well and had NO speech issues the next day.

My speech problem was talking slightly slurred, having problems pronouncing easy/ common words, trying to say a sentence I'd have the right words but they came out in the wrong order (jumbled up). I focused on eating high K foods and didn't take my coumadin that night (per clinic orders). Speech problems persisted till bedtime. Issues were gone next morning (even with taking a Tramadol that night as well.) I've been fine the rest of the week as well.

Chaconne, bruises were mild and hard to see but obviously there. Blue, green, yellow superficial kind. Faded but stayed a LONG time (about a week). No obvious reason for them (NO dropped marble, heavy objects, hitting trailer hitch, .... Any number of things we can do to ourselves to get hurt.) Showed up suddenly for no reason. I'm still crossing my legs and feet the same way when in bed and have not noticed any new bruises.

Main reason I was asking was to get a sense if sudden, unaccounted for bruises could be an indication of rising INRs. Sort of a physical indicator that INR might be getting too high and a bodily hint to go get tested? As a side note, I did notice that when my INR spiked up to 6 on Monday, I had some couple day old cat claw wounds that were well scabbed suddenly open back up and start bleeding on their own. No bleeding gums or other signs (except possibly for the speech problems). Expected a higher INR but nothing in that range!

From now on, if I see wounds bleeding when they shouldn't be or notice I'm having trouble talking, I'm going to go get tested.

Linda